Inspection on 06/02/06 for Oxenford House

This inspection was carried out on 6th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Oxenford House 30/11/06

Oxenford House 16/07/05

Oxenford House 22/12/04

Oxenford House 31/08/04

Oxenford House 06/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Oxenford House The Glebe Cumnor Oxford Oxfordshire OX2 9RL Lead Inspector Kate Harrison Unannounced Inspection 6th February 2006 1:15pm X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Oxenford House Address The Glebe Cumnor Oxford Oxfordshire OX2 9RL 01865 865116 01865 865923 care@oxenfordhouse.fsnet.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Abbeyfield Oxenford Society Limited Mrs Paulene Shaw Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability over 65 years of age (4) of places Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 25. 16th July 2005 Date of last inspection Brief Description of the Service: Oxenford House was purpose built and first registered in 1990, and is run by a charity The Abbeyfield Oxenford Society Ltd. The accommodation is on two floors with 25 bedrooms and a central lift. Ten of the bedrooms have en-suite facilities and one room is designated as a short stay for a holiday or convalescence. This room is also used for prospective residents who may like to experience living in the home whilst considering permanent residence. There is a spacious sitting room and dining room on the ground floor with a large conservatory leading into attractive gardens. There is also a small sitting room on the ground floor. There is a summerhouse at the rear of the home and ample space to walk around the gardens. The first floor has a small sitting room with kitchenette facilities. There are four bathrooms and a shower room. A ground floor room is used for hairdressing, aromatherapy and physiotherapy. A physiotherapist, a hairdresser, aromatherapist and reflexologist visit twice a week. The library service and chiropody visit monthly and a trolley shop service weekly. Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over one afternoon and was unexpected. The inspector met several residents and spoke to staff, residents and relatives about life at the home. The inspector saw communal and some private areas of the home and saw records and documents about how the home and residents are managed. Residents spoke highly of the attitude and skills of the staff. The inspector spent time with the registered manager and understood that the Executive Committee of the charity running the home, The Abbeyfield Society, supports her very well. The registered manager had previously completed and returned the CSCI preinspection questionnaire giving details on all aspects of the running of the home. Only those key standards not assessed at the inspection on July 16th 2005 were assessed at this inspection. What the service does well: What has improved since the last inspection? A review of the catering arrangements has taken place. Annual relatives’ meetings have started. A new sluice machine has been installed. All the windows in residents’ rooms are now double-glazed. Security at the front door has been improved. Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 6 Training for senior staff regarding management issues has taken place. The lighting in various areas of the house has been improved. Staff complete a new health and safety questionnaire every two months. New residents and staff are offered the opportunity to introduce themselves through a piece in the home’s newsletter. Two single rooms have been converted to en-suite rooms. An end of year audit took place in December 2005. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The registered manager makes sure that the home can meet the needs of residents before they are admitted. Standard 6 does not apply, as the home does not accept individuals for intermediate care. EVIDENCE: The inspector saw the files of two residents, one of whom had been recently admitted. The registered manager usually visits prospective residents to make sure that the home can meet the needs of the individual. All the necessary details were available about the two individuals assessed. Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9. Residents care needs are well documented. Medication is well managed but the receipt of medication must be recorded. EVIDENCE: The inspector checked individual care plans and noted that assessments of all needs were in place, including the physical and emotional needs of the individuals. Detailed care plans were in place to address the needs by care staff and other health professionals, for instance the district nurse was attending when necessary and nutritional supplements were obtained through the GP. The inspector noted that appropriate policies are in place to manage medication. Medication is ordered monthly and delivered weekly, though the inspector noted that an appropriate system for recording the receipt of the medication is not in place. Controlled drugs are stored and recorded appropriately. Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 10 It is a requirement that a system is in place to record the receipt of all medication from whatever source received into the home. This requirement was met within the timescale. Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The key standards were assessed at the inspection on 16th July 2005 and were not assessed at this inspection. Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. Policies and procedures are in place to protect residents from abuse. EVIDENCE: A review of the existing policies was taking place at the time of inspection, and current details about the Oxfordshire adult protection arrangements are included. All care staff have had training in the protection of vulnerable adults. Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The key standards were assessed at the inspection on 16th July 2005 and were not assessed at this inspection. Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30. Staff recruitment procedures need to be strengthened to meet regulations, and two requirements about the procedures are made in this report. Staff training is well managed. EVIDENCE: The inspector saw staff recruitment information and noted that not all the information required by the regulations was available. Photographs and proof of identity of all individuals working at the home must be available. The original certificate of clearance from the Criminal Records Bureau should be in place, and references should be obtained from the previous employer when a prospective care worker’s last job was in a care setting. This requirement was met within the timescale. The inspector discussed the arrangements regarding information about agency staff working at the home. The registered manager confirmed to the inspector that a general arrangement was in place, and agreed to check the arrangement and update if necessary to meet regulation. The home has an induction programme for new staff, which is carried out during the first six weeks at the home. New staff work with experienced carers and competencies are checked at the end of the six weeks. NVQ training is encouraged. All care staff are offered appropriate training, and training on Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 15 dementia as well as mandatory training on moving and handling and fire procedures has taken place recently. Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 and 38. The registered manager is experienced and knowledgeable. Residents’ petty cash is managed well. Health and safety issues are well managed. EVIDENCE: The registered manager is a registered nurse and has obtained the NVQ Level 4 in Management. She has several years experience of running the home. The inspector checked the arrangements for residents’ petty cash, and was satisfied that appropriate records are kept, and that property is kept securely. Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 17 The Abbeyfield Health and Safety policy statement is available at the home, and staff are asked to complete a health and safety questionnaire regularly. There is a named person responsible for safety issues at the home, and the inspector saw several policies on various safety topics. The fire safety checks and staff training lectures take place appropriately and are recorded. Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement A system must be in place to record the receipt of all medication from whatever source received into the home. All the information about staff detailed in Schedule 2 (amended 2004) and in Regulation 19 (amended 2004) of the Care Standards Act 2000 must be available. Timescale for action 28/02/06 2 OP29 19 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP29 OP29 Good Practice Recommendations The original certificate of clearance (not a photocopy) from the Criminal Records Bureau should be available for new staff. A reference should be obtained from the previous employer when a prospective care worker’s last job was in a care setting. Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Oxenford House DS0000013122.V282521.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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